1. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Chapter 9 Improving Quality in Health Care Organizations

2. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Objectives After completing this chapter, you will be able to: –Explain the importance of quality improvement (QI) in healthcare –Define quality and performance measures for organizations –Differentiate the important issues in defining, measuring, and using quality and performance measures

3. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Objectives (cont’d.) –Recognize the challenges of undertaking QI and QI implementation in HCOs –Distinguish among QI frameworks –Describe opportunities to apply QI tactics and strategies to support QI in HCOs –Assess conditions for QI change

4. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Objectives (cont’d.) –Justify the need to manage for QI in healthcare –Explain the importance of people and focusing on people issues in QI efforts –Describe management roles to create high- performance, quality-focused organizations

5. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Purpose Quality improvement (QI) interventions: designed to decrease medical errors and enhance patient safety –Demonstrate how health care organizations improve quality and patient safety through QI –Describe challenges and strategies for changing organizational systems to ensure that QI is accepted part of organizational behavior

6. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Quality Improvement in Health Care Major elements of quality: –Structure –Process –Outcomes Major aims for improvement in healthcare: –Safe, effective, patient-centered, timely, efficient, and equitable

7. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Quality Improvement (QI) Quality Improvement (QI): organized approach to planning and implementing continuous improvement in performance –Emphasizes continuous examination and improvement of work processes by teams –Stresses that quality depends on processes by which services are designed and delivered

8. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. QI Interventions Externally-developed QI: involves looking outside organization for new and/ or redesigned practices Locally-developed QI: improvement process begins with problem, but participants do not know what improved practices will look like

9. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Quality Measurement and Quality Improvement Quality measures and measurement: –Structural measures of quality: organization or an individual’s actions impact overall quality or organizational performance –Process measures of quality: indicators of activities involved in carrying out work in an organization –Outcome measures of quality: metrics based on results of work performed

10. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Using Quality Measures Variety of technical, organizational, and management issues often impede development and use of quality metrics Validity and attribution of outcomes-based quality measures are vigorously debated Additional problems center on focus of quality measures

11. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Developing Quality Measures Managers should attempt to follow several basic guidelines in developing quality measures for QI purposes: –Quality measures should be economical –Data on which quality measures are based must be timely –Quality measures must be actionable

12. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved.

13. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Approaches to Quality Improvement Focus on making improvements that are systematic, guided by data and efficient Key elements: continuous improvement, customer focus, structured processes, and organization-wide participation Continuous quality improvement vs. clinical practice guidelines Six sigma: measure and eliminate defects

14. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved.

15. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved.

16. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Getting to Higher Quality and Quality Improvement The challenge of implementation –Implementation: critical gateway between decision to adopt QI innovation and routine use of QI innovation –Implementation of new, innovative practices is demanding –QI implementation in healthcare organizations is challenging due to nature of work, workforce, and performance measurement and control systems

17. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved.

18. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. The Nature of Work in Healthcare Three areas of difference are particularly salient when considering importance of quality and QI in healthcare: –Risk (aversion) –Work norms –Clinician discretion

19. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Workforce Characteristics and Implementation Challenges Specialization –Only partial knowledge for patient care The physician culture –Less consideration of lower ranked individuals The professional hierarchy –Collaboration problems due to rankings Professional identification – Limits organizational identification

20. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Performance Measurement and Control Systems Collect data and reward specific behaviors Lack of performance measurement and control systems reflects: –Working hard equated with delivering best possible care –Limited information to challenge belief that effort is associated with best quality care –Developing valid measures of quality is difficult because of inherent nature of work

21. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Implementation Policies and Practices QI initiatives are often unsuccessful due to implementation failures Implementation policies and practices (IPPs) facilitate implementation by increasing employees’ capabilities, motivations, and opportunities to put innovation into use

22. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Organizational Infrastructure and Support Organizational structure Financial support Organizational culture Leadership and management support and engagement Governance leadership Learning climate

23. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Applying Quality Improvement Frameworks QI tactics and strategies: –Create opportunities for staff experimentation and QI adaptation –Frame QI as learning challenge –Promote organizational identification –Use transformational leadership processes –Involve workforce in performance measurement and control system –Measure/reward QI implementation efforts

24. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Build Evidence for QI QI intervention source: –Perceptions of key stakeholders about whether innovation is externally or internally developed may influence success of QI implementation Evidence strength and quality: –Sources of evidence: published literature, guidelines, anecdotal stories, competitors, patients’ experience, results from local pilot

25. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Keys to Successful QI Change- Perception Management QI change occurs in context of organizational events and histories related to change: –Shapes likelihood change will be successfully implemented –Both change and reason for change have to be understood

26. Copyright 2012 Delmar, a part of Cengage Learning. All Rights Reserved. Keys to Successful QI Change- Perception Management (cont’d.) Key principle affecting individual perceptions of QI change is potential threats to security Sequencing of QI can shape perceptions of those who participate in change Planning for change should acknowledge importance of “perception as reality” perspective